Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

VAC - RSV (ABRYSVO) [0.5 ML]

Facility

$707.00

Service Code	CPT 90678
Hospital Charge Code	8007080
Hospital Revenue Code	521
Min. Negotiated Rate	$494.90
Max. Negotiated Rate	$707.00
Rate for Payer: Aetna Commercial	$671.65
Rate for Payer: Aetna Medicare	$636.30
Rate for Payer: BCBS MT CHIP	$636.30
Rate for Payer: BCBS MT Closed Plan Network	$671.65
Rate for Payer: BCBS MT HealthLink	$636.30
Rate for Payer: BCBS MT Medicare	$636.30
Rate for Payer: BCBS MT POS	$671.65
Rate for Payer: BCBS MT Traditional	$707.00
Rate for Payer: Cash Price	$636.30
Rate for Payer: Cigna Commercial	$671.65
Rate for Payer: Cigna Medicare	$636.30
Rate for Payer: Medicaid All Medicaid	$650.44
Rate for Payer: Medicare All Medicare	$494.90
Rate for Payer: Monida Allegiance	$671.65
Rate for Payer: Monida First Choice Health	$685.79
Rate for Payer: Monida Montana Health Co-op	$671.65
Rate for Payer: Monida PacificSource	$671.65

VAC - RSV (ABRYSVO) [0.5 ML]

Facility

$707.00

Service Code	CPT 90678
Hospital Charge Code	8007080
Hospital Revenue Code	521
Min. Negotiated Rate	$494.90
Max. Negotiated Rate	$707.00
Rate for Payer: Aetna Commercial	$671.65
Rate for Payer: Aetna Medicare	$636.30
Rate for Payer: BCBS MT CHIP	$636.30
Rate for Payer: BCBS MT Closed Plan Network	$671.65
Rate for Payer: BCBS MT HealthLink	$636.30
Rate for Payer: BCBS MT Medicare	$636.30
Rate for Payer: BCBS MT POS	$671.65
Rate for Payer: BCBS MT Traditional	$707.00
Rate for Payer: Cash Price	$636.30
Rate for Payer: Cigna Commercial	$671.65
Rate for Payer: Cigna Medicare	$636.30
Rate for Payer: Medicaid All Medicaid	$650.44
Rate for Payer: Medicare All Medicare	$494.90
Rate for Payer: Monida Allegiance	$671.65
Rate for Payer: Monida First Choice Health	$685.79
Rate for Payer: Monida Montana Health Co-op	$671.65
Rate for Payer: Monida PacificSource	$671.65

VAC - RSV RECOMBINANT (AREXVY) [0.5 ML]

Facility

$677.00

Service Code	CPT 90679
Hospital Charge Code	8007078
Hospital Revenue Code	521
Min. Negotiated Rate	$473.90
Max. Negotiated Rate	$677.00
Rate for Payer: Aetna Commercial	$643.15
Rate for Payer: Aetna Medicare	$609.30
Rate for Payer: BCBS MT CHIP	$609.30
Rate for Payer: BCBS MT Closed Plan Network	$643.15
Rate for Payer: BCBS MT HealthLink	$609.30
Rate for Payer: BCBS MT Medicare	$609.30
Rate for Payer: BCBS MT POS	$643.15
Rate for Payer: BCBS MT Traditional	$677.00
Rate for Payer: Cash Price	$609.30
Rate for Payer: Cigna Commercial	$643.15
Rate for Payer: Cigna Medicare	$609.30
Rate for Payer: Medicaid All Medicaid	$622.84
Rate for Payer: Medicare All Medicare	$473.90
Rate for Payer: Monida Allegiance	$643.15
Rate for Payer: Monida First Choice Health	$656.69
Rate for Payer: Monida Montana Health Co-op	$643.15
Rate for Payer: Monida PacificSource	$643.15

VAC - RSV RECOMBINANT (AREXVY) [0.5 ML]

Facility

$677.00

Service Code	CPT 90679
Hospital Charge Code	8007078
Hospital Revenue Code	521
Min. Negotiated Rate	$473.90
Max. Negotiated Rate	$677.00
Rate for Payer: Aetna Commercial	$643.15
Rate for Payer: Aetna Medicare	$609.30
Rate for Payer: BCBS MT CHIP	$609.30
Rate for Payer: BCBS MT Closed Plan Network	$643.15
Rate for Payer: BCBS MT HealthLink	$609.30
Rate for Payer: BCBS MT Medicare	$609.30
Rate for Payer: BCBS MT POS	$643.15
Rate for Payer: BCBS MT Traditional	$677.00
Rate for Payer: Cash Price	$609.30
Rate for Payer: Cigna Commercial	$643.15
Rate for Payer: Cigna Medicare	$609.30
Rate for Payer: Medicaid All Medicaid	$622.84
Rate for Payer: Medicare All Medicare	$473.90
Rate for Payer: Monida Allegiance	$643.15
Rate for Payer: Monida First Choice Health	$656.69
Rate for Payer: Monida Montana Health Co-op	$643.15
Rate for Payer: Monida PacificSource	$643.15

VAC - TETANUS DIP PERTUSSIS - TDAP

Facility

$212.00

Service Code	CPT 90715
Hospital Charge Code	8007035
Hospital Revenue Code	521
Min. Negotiated Rate	$148.40
Max. Negotiated Rate	$212.00
Rate for Payer: Aetna Commercial	$201.40
Rate for Payer: Aetna Medicare	$190.80
Rate for Payer: BCBS MT CHIP	$190.80
Rate for Payer: BCBS MT Closed Plan Network	$201.40
Rate for Payer: BCBS MT HealthLink	$190.80
Rate for Payer: BCBS MT Medicare	$190.80
Rate for Payer: BCBS MT POS	$201.40
Rate for Payer: BCBS MT Traditional	$212.00
Rate for Payer: Cash Price	$190.80
Rate for Payer: Cigna Commercial	$201.40
Rate for Payer: Cigna Medicare	$190.80
Rate for Payer: Medicaid All Medicaid	$195.04
Rate for Payer: Medicare All Medicare	$148.40
Rate for Payer: Monida Allegiance	$201.40
Rate for Payer: Monida First Choice Health	$205.64
Rate for Payer: Monida Montana Health Co-op	$201.40
Rate for Payer: Monida PacificSource	$201.40

VAC - TETANUS DIP PERTUSSIS - TDAP

Facility

$212.00

Service Code	CPT 90715
Hospital Charge Code	8007035
Hospital Revenue Code	521
Min. Negotiated Rate	$148.40
Max. Negotiated Rate	$212.00
Rate for Payer: Aetna Commercial	$201.40
Rate for Payer: Aetna Medicare	$190.80
Rate for Payer: BCBS MT CHIP	$190.80
Rate for Payer: BCBS MT Closed Plan Network	$201.40
Rate for Payer: BCBS MT HealthLink	$190.80
Rate for Payer: BCBS MT Medicare	$190.80
Rate for Payer: BCBS MT POS	$201.40
Rate for Payer: BCBS MT Traditional	$212.00
Rate for Payer: Cash Price	$190.80
Rate for Payer: Cigna Commercial	$201.40
Rate for Payer: Cigna Medicare	$190.80
Rate for Payer: Medicaid All Medicaid	$195.04
Rate for Payer: Medicare All Medicare	$148.40
Rate for Payer: Monida Allegiance	$201.40
Rate for Payer: Monida First Choice Health	$205.64
Rate for Payer: Monida Montana Health Co-op	$201.40
Rate for Payer: Monida PacificSource	$201.40

VAC - TRUMEMBA -MENINGOCOCCAL B [0.5 ML]

Facility

$605.00

Service Code	CPT 90621
Hospital Charge Code	8007029
Hospital Revenue Code	521
Min. Negotiated Rate	$423.50
Max. Negotiated Rate	$605.00
Rate for Payer: Aetna Commercial	$574.75
Rate for Payer: Aetna Medicare	$544.50
Rate for Payer: BCBS MT CHIP	$544.50
Rate for Payer: BCBS MT Closed Plan Network	$574.75
Rate for Payer: BCBS MT HealthLink	$544.50
Rate for Payer: BCBS MT Medicare	$544.50
Rate for Payer: BCBS MT POS	$574.75
Rate for Payer: BCBS MT Traditional	$605.00
Rate for Payer: Cash Price	$544.50
Rate for Payer: Cigna Commercial	$574.75
Rate for Payer: Cigna Medicare	$544.50
Rate for Payer: Medicaid All Medicaid	$556.60
Rate for Payer: Medicare All Medicare	$423.50
Rate for Payer: Monida Allegiance	$574.75
Rate for Payer: Monida First Choice Health	$586.85
Rate for Payer: Monida Montana Health Co-op	$574.75
Rate for Payer: Monida PacificSource	$574.75

VAC - TRUMEMBA -MENINGOCOCCAL B [0.5 ML]

Facility

$605.00

Service Code	CPT 90621
Hospital Charge Code	8007029
Hospital Revenue Code	521
Min. Negotiated Rate	$423.50
Max. Negotiated Rate	$605.00
Rate for Payer: Aetna Commercial	$574.75
Rate for Payer: Aetna Medicare	$544.50
Rate for Payer: BCBS MT CHIP	$544.50
Rate for Payer: BCBS MT Closed Plan Network	$574.75
Rate for Payer: BCBS MT HealthLink	$544.50
Rate for Payer: BCBS MT Medicare	$544.50
Rate for Payer: BCBS MT POS	$574.75
Rate for Payer: BCBS MT Traditional	$605.00
Rate for Payer: Cash Price	$544.50
Rate for Payer: Cigna Commercial	$574.75
Rate for Payer: Cigna Medicare	$544.50
Rate for Payer: Medicaid All Medicaid	$556.60
Rate for Payer: Medicare All Medicare	$423.50
Rate for Payer: Monida Allegiance	$574.75
Rate for Payer: Monida First Choice Health	$586.85
Rate for Payer: Monida Montana Health Co-op	$574.75
Rate for Payer: Monida PacificSource	$574.75

VAC - VARICELLA [0.5ML]

Facility

$239.00

Service Code	CPT 90716
Hospital Charge Code	8007086
Hospital Revenue Code	521
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$239.00
Rate for Payer: Aetna Commercial	$227.05
Rate for Payer: Aetna Medicare	$215.10
Rate for Payer: BCBS MT CHIP	$215.10
Rate for Payer: BCBS MT Closed Plan Network	$227.05
Rate for Payer: BCBS MT HealthLink	$215.10
Rate for Payer: BCBS MT Medicare	$215.10
Rate for Payer: BCBS MT POS	$227.05
Rate for Payer: BCBS MT Traditional	$239.00
Rate for Payer: Cash Price	$215.10
Rate for Payer: Cigna Commercial	$227.05
Rate for Payer: Cigna Medicare	$215.10
Rate for Payer: Medicaid All Medicaid	$219.88
Rate for Payer: Medicare All Medicare	$167.30
Rate for Payer: Monida Allegiance	$227.05
Rate for Payer: Monida First Choice Health	$231.83
Rate for Payer: Monida Montana Health Co-op	$227.05
Rate for Payer: Monida PacificSource	$227.05

VAC - VARICELLA [0.5ML]

Facility

$239.00

Service Code	CPT 90716
Hospital Charge Code	8007086
Hospital Revenue Code	521
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$239.00
Rate for Payer: Aetna Commercial	$227.05
Rate for Payer: Aetna Medicare	$215.10
Rate for Payer: BCBS MT CHIP	$215.10
Rate for Payer: BCBS MT Closed Plan Network	$227.05
Rate for Payer: BCBS MT HealthLink	$215.10
Rate for Payer: BCBS MT Medicare	$215.10
Rate for Payer: BCBS MT POS	$227.05
Rate for Payer: BCBS MT Traditional	$239.00
Rate for Payer: Cash Price	$215.10
Rate for Payer: Cigna Commercial	$227.05
Rate for Payer: Cigna Medicare	$215.10
Rate for Payer: Medicaid All Medicaid	$219.88
Rate for Payer: Medicare All Medicare	$167.30
Rate for Payer: Monida Allegiance	$227.05
Rate for Payer: Monida First Choice Health	$231.83
Rate for Payer: Monida Montana Health Co-op	$227.05
Rate for Payer: Monida PacificSource	$227.05

VAC - VAXELIS -DTaP-IPV-Hib-Hep B [0.5ML

Facility

$508.00

Service Code	CPT 90697
Hospital Charge Code	3007093
Hospital Revenue Code	250
Min. Negotiated Rate	$355.60
Max. Negotiated Rate	$508.00
Rate for Payer: Aetna Commercial	$482.60
Rate for Payer: Aetna Medicare	$457.20
Rate for Payer: BCBS MT CHIP	$457.20
Rate for Payer: BCBS MT Closed Plan Network	$482.60
Rate for Payer: BCBS MT HealthLink	$457.20
Rate for Payer: BCBS MT Medicare	$457.20
Rate for Payer: BCBS MT POS	$482.60
Rate for Payer: BCBS MT Traditional	$508.00
Rate for Payer: Cash Price	$457.20
Rate for Payer: Cigna Commercial	$482.60
Rate for Payer: Cigna Medicare	$457.20
Rate for Payer: Medicaid All Medicaid	$467.36
Rate for Payer: Medicare All Medicare	$355.60
Rate for Payer: Monida Allegiance	$482.60
Rate for Payer: Monida First Choice Health	$492.76
Rate for Payer: Monida Montana Health Co-op	$482.60
Rate for Payer: Monida PacificSource	$482.60

VAC - VAXELIS -DTaP-IPV-Hib-Hep B [0.5ML

Facility

$508.00

Service Code	CPT 90697
Hospital Charge Code	3007093
Hospital Revenue Code	250
Min. Negotiated Rate	$355.60
Max. Negotiated Rate	$508.00
Rate for Payer: Aetna Commercial	$482.60
Rate for Payer: Aetna Medicare	$457.20
Rate for Payer: BCBS MT CHIP	$457.20
Rate for Payer: BCBS MT Closed Plan Network	$482.60
Rate for Payer: BCBS MT HealthLink	$457.20
Rate for Payer: BCBS MT Medicare	$457.20
Rate for Payer: BCBS MT POS	$482.60
Rate for Payer: BCBS MT Traditional	$508.00
Rate for Payer: Cash Price	$457.20
Rate for Payer: Cigna Commercial	$482.60
Rate for Payer: Cigna Medicare	$457.20
Rate for Payer: Medicaid All Medicaid	$467.36
Rate for Payer: Medicare All Medicare	$355.60
Rate for Payer: Monida Allegiance	$482.60
Rate for Payer: Monida First Choice Health	$492.76
Rate for Payer: Monida Montana Health Co-op	$482.60
Rate for Payer: Monida PacificSource	$482.60

VAC - ZOSTER RECOMB (SHINGRIX) [0.5 ML]

Facility

$583.25

Service Code	CPT 90750
Hospital Charge Code	8007079
Hospital Revenue Code	521
Min. Negotiated Rate	$408.27
Max. Negotiated Rate	$583.25
Rate for Payer: Aetna Commercial	$554.09
Rate for Payer: Aetna Medicare	$524.92
Rate for Payer: BCBS MT CHIP	$524.92
Rate for Payer: BCBS MT Closed Plan Network	$554.09
Rate for Payer: BCBS MT HealthLink	$524.92
Rate for Payer: BCBS MT Medicare	$524.92
Rate for Payer: BCBS MT POS	$554.09
Rate for Payer: BCBS MT Traditional	$583.25
Rate for Payer: Cash Price	$524.93
Rate for Payer: Cigna Commercial	$554.09
Rate for Payer: Cigna Medicare	$524.92
Rate for Payer: Medicaid All Medicaid	$536.59
Rate for Payer: Medicare All Medicare	$408.27
Rate for Payer: Monida Allegiance	$554.09
Rate for Payer: Monida First Choice Health	$565.75
Rate for Payer: Monida Montana Health Co-op	$554.09
Rate for Payer: Monida PacificSource	$554.09

VAC - ZOSTER RECOMB (SHINGRIX) [0.5 ML]

Facility

$583.25

Service Code	CPT 90750
Hospital Charge Code	8007079
Hospital Revenue Code	521
Min. Negotiated Rate	$408.27
Max. Negotiated Rate	$583.25
Rate for Payer: Aetna Commercial	$554.09
Rate for Payer: Aetna Medicare	$524.92
Rate for Payer: BCBS MT CHIP	$524.92
Rate for Payer: BCBS MT Closed Plan Network	$554.09
Rate for Payer: BCBS MT HealthLink	$524.92
Rate for Payer: BCBS MT Medicare	$524.92
Rate for Payer: BCBS MT POS	$554.09
Rate for Payer: BCBS MT Traditional	$583.25
Rate for Payer: Cash Price	$524.93
Rate for Payer: Cigna Commercial	$554.09
Rate for Payer: Cigna Medicare	$524.92
Rate for Payer: Medicaid All Medicaid	$536.59
Rate for Payer: Medicare All Medicare	$408.27
Rate for Payer: Monida Allegiance	$554.09
Rate for Payer: Monida First Choice Health	$565.75
Rate for Payer: Monida Montana Health Co-op	$554.09
Rate for Payer: Monida PacificSource	$554.09

VAGINAL SPECULUMS SM

Facility

$18.00

Hospital Charge Code	80040099
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

VAGINAL SPECULUMS SM

Facility

$18.00

Hospital Charge Code	80040099
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

VAGINITIS PANEL PCR

Facility

$460.00

Service Code	CPT 81514
Hospital Charge Code	4081514
Hospital Revenue Code	300
Min. Negotiated Rate	$322.00
Max. Negotiated Rate	$460.00
Rate for Payer: Aetna Commercial	$437.00
Rate for Payer: Aetna Medicare	$414.00
Rate for Payer: BCBS MT CHIP	$414.00
Rate for Payer: BCBS MT Closed Plan Network	$437.00
Rate for Payer: BCBS MT HealthLink	$414.00
Rate for Payer: BCBS MT Medicare	$414.00
Rate for Payer: BCBS MT POS	$437.00
Rate for Payer: BCBS MT Traditional	$460.00
Rate for Payer: Cash Price	$414.00
Rate for Payer: Cigna Commercial	$437.00
Rate for Payer: Cigna Medicare	$414.00
Rate for Payer: Medicaid All Medicaid	$423.20
Rate for Payer: Medicare All Medicare	$322.00
Rate for Payer: Monida Allegiance	$437.00
Rate for Payer: Monida First Choice Health	$446.20
Rate for Payer: Monida Montana Health Co-op	$437.00
Rate for Payer: Monida PacificSource	$437.00

VAGINITIS PANEL PCR

Facility

$460.00

Service Code	CPT 81514
Hospital Charge Code	4081514
Hospital Revenue Code	300
Min. Negotiated Rate	$322.00
Max. Negotiated Rate	$460.00
Rate for Payer: Aetna Commercial	$437.00
Rate for Payer: Aetna Medicare	$414.00
Rate for Payer: BCBS MT CHIP	$414.00
Rate for Payer: BCBS MT Closed Plan Network	$437.00
Rate for Payer: BCBS MT HealthLink	$414.00
Rate for Payer: BCBS MT Medicare	$414.00
Rate for Payer: BCBS MT POS	$437.00
Rate for Payer: BCBS MT Traditional	$460.00
Rate for Payer: Cash Price	$414.00
Rate for Payer: Cigna Commercial	$437.00
Rate for Payer: Cigna Medicare	$414.00
Rate for Payer: Medicaid All Medicaid	$423.20
Rate for Payer: Medicare All Medicare	$322.00
Rate for Payer: Monida Allegiance	$437.00
Rate for Payer: Monida First Choice Health	$446.20
Rate for Payer: Monida Montana Health Co-op	$437.00
Rate for Payer: Monida PacificSource	$437.00

VALACYCLOVIR TAB [500 MG]

Facility

$24.00

Service Code	HCPCS J8499
Hospital Charge Code	3000469
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

VALACYCLOVIR TAB [500 MG]

Facility

$24.00

Service Code	HCPCS J8499
Hospital Charge Code	3000469
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

VALIUM 5MG/ML IM

Facility

$26.00

Service Code	HCPCS J3360
Hospital Charge Code	640701
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

VALIUM 5MG/ML IM

Facility

$26.00

Service Code	HCPCS J3360
Hospital Charge Code	640701
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

VALPROIC ACID (007260)

Facility

$70.00

Service Code	CPT 80164
Hospital Charge Code	4080164
Hospital Revenue Code	301
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

VALPROIC ACID (007260)

Facility

$70.00

Service Code	CPT 80164
Hospital Charge Code	4080164
Hospital Revenue Code	301
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

VALPROIC ACID CAP [250 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000592
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

Know your out-of-pocket cost for care.

All Charges